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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 06/09/2022
Date Signed: 06/09/2022 03:13:58 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2022 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220603145532
FACILITY NAME:GLEN PARK AT GLENDALE - MARIPOSA STFACILITY NUMBER:
197608506
ADMINISTRATOR:PINK, MARINAFACILITY TYPE:
740
ADDRESS:1220 S MARIPOSA STTELEPHONE:
(818) 242-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:120CENSUS: 69DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator Rachel De ChavezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not keep resident's records confidential
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Rachel De Chavez and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Assistant Administrator Rachel De Chavez, Receptionist Darkis Giron and Resident 1-7 (R1-7). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of the following documents: Identification and Emergency Information (LIC601),Physician's Report for Residential Care Facilities for the Elderly (RCFE) dated 2/8/22, Functional Capability Assessment (LIC9172) dated 2/14/22, Individual Service Plan (ISP) dated 2/9/22, Physician's Orders for Life Sustaining Treatment (POLST) dated 11/24/20 and Internal Resident Incident Reports for dates 2/17/22 - 6/1/22. LPA also attempted a call to The Gardens of El Monte.

(See LIC9099C for continuation)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20220603145532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GLEN PARK AT GLENDALE - MARIPOSA ST
FACILITY NUMBER: 197608506
VISIT DATE: 06/09/2022
NARRATIVE
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Investigation revealed the following: Regarding allegation of, Staff did not keep resident's records confidential, it is alleged that R1's family member (FM1) is not listed on any emergency forms at the facility and is not R1's authorized representative. R1 does not want any communication with FM1 and it is alleged that facility staff disclosed information to FM1 about R1's medical records and violated HIPAA. Interview with Assistant Administrator Rachel De Chavez revealed that facility has never violated any facility resident's confidential information. Ms. De Chavez stated that there are some residents that have responsible parties, Power of Attorney's and authorized representatives which information is on record and only then is information disclosed regarding a resident. She stated that if a resident is independent their private, confidential information is always kept confidential. She stated that R1 recently accused the facility of not keeping their records confidential. Ms. De Chavez stated that the facility does not have any of R1's family members information on record and only has R1's information as the resident is self responsible. Interview with Staff Giron revealed that on 6/1/22, R1 called the front desk yelling and stating that the facility needed to keep their information private. Staff Darkis stated that she then reviewed R1's file and did not see any other contact information besides R1's contact information and also saw that R'1 is self responsible. Interviews with 6 out of 7 residents revealed that they are satisfied with all services received at the facility and have not had any issues or concerns regarding the facility not keeping their records confidential. 6 out of 7 residents stated that they do not have any concerns regarding the facility, the services received or their interactions with facility staff. Interview with R1 revealed that they reviewed their Physician's Orders for Life Sustaining Treatment (POLST) dated 11/24/20 and saw that FM1's information was noted down. LPA reviewed R1's facility file which revealed that R1 was admitted to the facility on 2/14/22. LPA collected a copy of R1's POLST and review of the document did reveal that FM1's name and contact information was listed but this document was completed on 11/24/20 by a staff at a short-term rehabilitation facility that R1 resided at before being admitted to Glen Park at Glendale - Mariposa St.

Based on LPA interviews with facility staff, facility residents and LPA review of documentation which revealed that the document that listed R1's FM1 was not completed by staff at Glen Park at Glendale - Mariposa St. LPA Gonzalez determined that there was insufficient evidence to support the above stated allegation.

This agency has investigated the complaint alleging, Staff did not keep resident's records confidential. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Exit interview held. A copy of the report was provided to Assistant Administrator Rachel De Chavez.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
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